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10311013
RenalCJASN
Physiology
Abstract
Renal nitrogen metabolism primarily involves urea and ammonia metabolism, and is essential to normal health.
Urea is the largest circulating pool of nitrogen, excluding nitrogen in circulating proteins, and its production
changes in parallel to the degradation of dietary and endogenous proteins. In addition to serving as a way to
excrete nitrogen, urea transport, mediated through specific urea transport proteins, mediates a central role in the
urine concentrating mechanism. Renal ammonia excretion, although often considered only in the context of acidbase homeostasis, accounts for approximately 10% of total renal nitrogen excretion under basal conditions, but
can increase substantially in a variety of clinical conditions. Because renal ammonia metabolism requires
intrarenal ammoniagenesis from glutamine, changes in factors regulating renal ammonia metabolism can have
important effects on glutamine in addition to nitrogen balance. This review covers aspects of protein metabolism
and the control of the two major molecules involved in renal nitrogen excretion: urea and ammonia. Both urea and
ammonia transport can be altered by glucocorticoids and hypokalemia, two conditions that also affect protein
metabolism. Clinical conditions associated with altered urine concentrating ability or water homeostasis can
result in changes in urea excretion and urea transporters. Clinical conditions associated with altered ammonia
excretion can have important effects on nitrogen balance.
Clin J Am Soc Nephrol : cccccc, 2014. doi: 10.2215/CJN.10311013
Introduction
Nitrogen metabolism is necessary for normal health.
Nitrogen is an essential element present in all amino
acids; it is derived from dietary protein intake, is
necessary for protein synthesis and maintenance of
muscle mass, and is excreted by the kidneys. Under
steady-state conditions, renal nitrogen excretion
equals nitrogen intake. Renal nitrogen excretion consists almost completely of urea and ammonia. (To note,
ammonia exists in two distinct molecular forms, NH3
and NH41, which are in equilibrium with each other.
In this review, we use the term ammonia to refer to the
combination of both molecular forms. When referring
to a specic molecular form, we state either NH3 or
NH41.) Other nitrogen compounds (e.g., nitric oxide
metabolites, and nitrates) and many nitrogen-containing
compounds (e.g., uric acid, urinary protein, etc.), comprise ,1% of total renal nitrogen excretion. The two
major components of renal nitrogen excretion, urea
and ammonia, are regulated by a wide variety of conditions and play important roles in normal health and
disease, including roles in the urine concentrating mechanism and in acid-base homeostasis. In this review, we
discuss the mechanisms and regulation of both urea and
ammonia handling in the kidneys, their roles in renal
physiologic responses other than nitrogen excretion, and
the clinical uses of urea production and metabolism.
Urea Introduction
Proteins throughout the body are continually turning over but at vastly different rates: consider the
www.cjasn.org Vol 0 , 2014
*Nephrology and
Hypertension Section,
North Florida/South
Georgia Veterans
Health System,
Gainesville, Florida;
Division of
Nephrology,
Hypertension, and
Transplantation,
University of Florida
College of Medicine,
Gainesville, Florida;
Nephrology Division,
Baylor College of
Medicine, Houston,
Texas; and
Nephrology Division,
Emory University
School of Medicine,
Atlanta, Georgia
Correspondence:
Dr. I. David Weiner,
Division of Nephrology,
Hypertension, and
Transplantation,
University of Florida
College of Medicine,
P.O. Box 100224,
Gainesville, FL 32610.
Email: david.weiner@
medicine.ufl.edu
Urea Transport
Figure 2. | Urea transporters along the nephron. The cartoon and histology show the urea transporters (UT-A1/UT-A3, UT-A2, and UT-B1)
along the nephron. UT-B1 is found chiefly in the vasa recta, UT-A2 is found in the thin descending limb of the loop of Henle, and UT-A1 (apical)
and UT-A3 (basolateral) are found in the inner medullary collecting duct. Modified from reference 12, with permission.
Figure 3. | The four renal UT-A protein isoforms. UT-A1 is the largest protein containing 12 transmembrane helices. Helices 6 and 7 are
connected by a large intracellular loop that recent studies have shown is crucial to the functional properties of UT-A1 (1). UT-A3 is the
N-terminal half of UT-A1, whereas UT-A2 is the C-terminal half of UT-A1. UT-A4 is the N-terminal quarter of UT-A1 spliced to the C-terminal
quarter. Modified from reference 13, with permission.
Figure 4. | Structure of the nephron. The cartoon depicts the cortex (top), outer medulla (middle), and inner medulla (bottom), showing the location of
the various substructures of the nephron labeled as follows: 1, glomerulus; 2, proximal convoluted tubule; 3s and 3l, proximal straight tubule in the shortlooped nephron (3s) and long looped nephron (3l); 4s and 4l, thin descending limb; 5, thin ascending limb; 6s and 6l, medullary thick ascending limb; 7,
macula densa; 8, distal convoluted tubule; 9, cortical collecting duct; 10, outer medullary collecting duct; 11, initial inner medullary collecting duct; and
12, terminal inner medullary collecting duct. Modified from reference 11, with permission of the American Physiological Society.
Figure 5. | Measured urea permeabilities in the different nephron sections of a rat kidney. CCD, cortical collecting duct; DCT, distal convoluted tubule;
IMCD, inner medullary collecting duct; mTAL, medullary thick ascending limb; OMCD, outer medullary collecting duct; PCT, proximal convoluted
tubule; PST, proximal straight tubule; tAL, thin ascending limb; tDL, thin descending limb. Modified from reference 11, with permission of the American
Physiological Society.
water in renal function referable to urea (19). Protein deprivation reduces maximal urine concentrating ability and is
restored by urea infusion or correction of the protein malnutrition (11,16). Decreased maximal urine concentrating
ability is present in several genetically engineered mice
Figure 6. | Urea transport across an IMCD cell. Vasopressin binds to the V2R, located on the basolateral plasma membrane, and activates the a
subunit of the heterotrimeric G protein Gsa. Activation of the G protein stimulates AC to synthesize cAMP. The increase of intracellular cAMP
stimulates several downstream proteins including PKA and Epac, which phosphorylate UT-A1 and increase its accumulation in the apical
plasma membrane. Urea enters the IMCD cell through UT-A1 and exits on the basolateral plasma membrane via UT-A3. AC, adenylyl cyclase;
Epac, exchange protein directly activated by cAMP; Gs, G protein stimulatory subunit; P, phosphate; PKA, protein kinase A; V2R, V2 vasopressin
receptor. Modified from reference 13 with permission.
loss of kidney concentrating ability (increase in urine volume and a decrease in urine osmolality) that occurs during
acidosis (43).
Hypokalemia. Prolonged hypokalemia can cause a decrease in urine concentrating ability (44). The abundance of
UT-A1, UT-A3, and UT-B1 proteins in the inner medulla is
reduced in rats fed a potassium-restricted diet (44,45). UTA2 protein abundance was reduced in one study but increased in another (44,45). The reason for the different
ndings is unclear.
In summary, renal urea transport and urea transport
proteins mediate a central role in the urine concentrating
mechanism. Urine concentrating defects have been demonstrated in several urea transporter knockout mice
(11,12,16). In many clinical conditions associated with altered urine concentrating ability or water homeostasis,
changes in urea excretion and urea transporters may be
contributory factors.
Ammonia
Physiologic Role for Ammonia
Kidneys mediate a central role in acid-base homeostasis
through the combined functions of ltered bicarbonate
reabsorption and new bicarbonate generation. Bicarbonate
reabsorption is necessary for acid-base homeostasis, but it
is not sufcient. New bicarbonate must be generated to
replace the bicarbonate that buffered endogenous and
exogenous acids. New bicarbonate generation involves
urinary ammonia and titratable acid excretion. Ammonia
excretion accounts for the majority of basal bicarbonate generation and changes in ammonia excretion are the primary
response to acid-base disorders (Figure 7). Nitrogen excretion
in the form of ammonia is approximately 10% of urea nitrogen excretion in basal conditions, but can increase 5- to 10fold, enabling ammonia to have an important role in nitrogen
balance.
Renal Ammonia Handling
Overview. Renal ammonia metabolism differs in important ways from that of other renal solutes. Other renal solutes
undergo net excretion, such that renal venous content is less
than arterial content. Ammonia is fundamentally different.
Almost all urinary ammonia is produced in the kidney
(47), and renal venous ammonia exceeds arterial ammonia, meaning that the kidneys actually increase systemic
ammonia. Ammonia undergoes a complex set of transport
events in the kidney, which determines the proportion of
ammonia generated that is excreted in the urine as ammonia nitrogen versus that which enters the renal capillaries
and is transported to the systemic circulation through the
renal veins.
Renal Ammoniagenesis. Renal ammoniagenesis occurs
primarily in the proximal tubule and glutamine is the primary
substrate (48). In the proximal tubule, glutamine uptake occurs through the combination of the apical Na1-dependent
neutral amino acid transporter-1, and the basolateral sodiumcoupled neutral amino acid transporter-3 (SNAT3) (49).
Changes in ammoniagenesis, such as during metabolic acidosis, are associated with changes in the expression of
SNAT3, but not expression of apical Na1-dependent neutral
amino acid transporter-1 (50). Ammoniagenesis primarily
Figure 7. | Responses of urinary ammonia and titratable acid excretion to exogenous acid loads. Normal humans were acid loaded,
and changes in urinary ammonia and titratable acid excretion were
determined on days 1, 3, and 5 of acid loading. Changes in urinary
ammonia excretion are the quantitatively predominant response
mechanism on each day, and continued to increase over the 5 days of
the experiment. Titratable acid excretion is a minor component of the
increase in net acid excretion, and peaks on day 1 of acid loading.
Data calculated from reference 46.
involves phosphate-dependent glutaminase, glutamate dehydrogenase, a-ketoglutarate dehydrogenase, and phosphoenolpyruvate carboxykinase (PEPCK) (47,51), and
complete glutamine metabolism generates two NH41 and
two HCO32 ions per glutamine. The bicarbonate produced
is then transported across the basolateral membrane via
electrogenic sodium-coupled bicarbonate co-transporter,
isoform 1A (NBCe-1A), and serves as new bicarbonate
generated by the kidney.
Ammonia Transport Overview
Only approximately 50% of the ammonia produced is
excreted in urine under basal conditions. The remaining
ammonia enters the systemic circulation through the renal
veins. Ammonia that enters the systemic circulation undergoes almost complete metabolism in the liver; the major
metabolic pathway uses HCO32 as a substrate, and generates urea. Consequently, ammonia produced in the kidney,
transported to the systemic circulation, and metabolized in
the liver to urea has no net acid-base benet.
The proportion of the ammonia produced that is excreted
in the urine, as opposed to being transported into the
systemic circulation, can be rapidly altered. This enables
changes in urinary ammonia to exceed, at least acutely,
changes in ammoniagenesis (52). In most chronic acid-base
disturbances, changes in ammoniagenesis account for the
majority of the changes in urinary ammonia content (47).
Importantly, renal epithelial cell ammonia transport determines the proportion of ammonia excreted in the urine.
Ammonia Transport. Ammonia produced in the proximal tubule is secreted preferentially into the luminal uid
(Figure 8). This appears to involve NH41 secretion by the
apical NHE3; there may also be a component of parallel
H1 and NH3 secretion (5355). Conditions associated with
NHE3 activation, such as metabolic acidosis and hypokalemia, also increase ammonia secretion (54).
Figure 8. | Model of proximal ammonia transport. Glutamine serves as the primary metabolic substrate for ammoniagenesis. Proximal tubule
glutamine uptake involves transport across the apical membrane, primarily via BoAT-1, and across the basolateral membrane by SNAT3. Complete
metabolism of each glutamine results in generation of two NH41 and two bicarbonate ions. Bicarbonate is transported across the basolateral
membrane via NBCe-1A. Ammonium secretion across the apical membrane occurs primarily via NHE3-mediated Na1/NH41 exchange, with
a lesser contribution by parallel H1 and NH3 transport. BoAT-1, apical Na1-dependent neutral amino acid transporter-1; NBCe-1A, electrogenic
sodium-bicarbonate cotransporter, isoform 1A; NHE3, sodium/hydrogen exchanger 3; SNAT3, sodium-coupled neutral amino acid transporter-3.
Figure 9. | Ammonia reabsorption by the thick ascending limb. Primary mechanism of apical ammonium absorption is via substitution of
NH41 for K1 and transport by the loop diuretic-sensitive, apical NKCC2 transporter. Cytoplasmic NH41 is transported across the basolateral
membrane either via Na1/NH41 exchange mediated by NHE4 or via a bicarbonate shuttling mechanism involving NH3 transport. NBCn1,
electroneutral sodium bicarbonate cotransporter, isoform 1; NHE4, sodium/hydrogen exchanger 4.
Figure 10. | Ammonia secretion by the collecting duct. Ammonia uptake across the basolateral membrane primarily involves either transportermediated uptake across the basolateral membrane by Rhbg or Rhcg, with a component of diffusive NH3 absorption. Cytosolic NH3 is transported across
the apical membrane by a combination of Rhcg and diffusive transport. In the IMCD, but not the CCD, basolateral Na1-K1-ATPase also contributes to
NH41 uptake across the basolateral membrane. Cytosolic H1 is generated by a carbonic anhydrase IImediated mechanism, and is secreted across the
apical membrane via H1-ATPase and H1-K1-ATPase. Luminal H1 titrates luminal NH3, forming NH41 and maintaining a low luminal NH3 concentration necessary for NH3 secretion. CAII, carbonic anhydrase isoform II; Rhbg, Rhesus B glycoprotein; Rhcg, Rhesus C glycoprotein.
10
Figure 11. | Integrated overview of renal ammonia metabolism. Renal ammoniagenesis occurs primarily in the proximal tubule, involving glutamine uptake by SNAT3 and BoAT-1, glutamine metabolism forming ammonium and bicarbonate, and apical NH41 secretion involving NHE3 and
parallel H1 and NH3 transport. Ammonia reabsorption in the thick ascending limb, involving apical NKCC2-mediated uptake results in medullary
ammonia accumulation. Medullary sulfatides (highlighted in green) reversibly bind NH41, contributing to medullary accumulation. Ammonia is secreted in the collecting duct via parallel H1 and NH3 secretion. The numbers in blue represent the proportion of total excreted ammonia. BoAT-1, apical
Na1-dependent neutral amino acid transporter-1; gsc, galactosylceramide backbone; PDG, phosphate-dependent glutaminase.
11
Figure 12. | Urea excretion in adult humans with varying degrees of kidney malfunction fed milk, egg, or an amino acid mixture: assessment
of nitrogen balance. Modified from reference 82, with permission.
to the daily protein intake (Figure 12). The only other assumption is that urea clearance is independent of the
plasma urea concentration, which is reasonable for patients with CKD. The key concept is that steady-state concentrations of nitrogen-containing waste product
produced during protein catabolism will increase in parallel to an increase in the SSUN (4,82,89). By varying the
amount of dietary protein, changes in the diet can be integrated with different values of the SSUN. As shown in
Table 1, similar concepts can be used to determine
whether a patient is complying with the prescribed protein
content of the diet (81,86,88).
These examples emphasize that the net production of
urea in patients with CKD (also known as the urea appearance rate) can be used to estimate protein intake
(4,82,89). For dialysis patients, the same relationships have
been labeled as urea generation or the normalized protein catabolic rate (nPCR). Obviously, the nPCR equals
the net urea production rate or the urea appearance rate
except that it is not expressed per kilogram of body
12
weight. However, the designation nPCR is misleading because the rates of protein synthesis and catabolism are
far greater than the protein catabolic rate: The nitrogen
ux in protein synthesis and degradation amounts to 45
55 g nitrogen/d, equivalent to 280350 g protein/d (1).
The principle of conservation of mass, however, indicates
the difference between whole-body protein synthesis and
degradation does estimate waste nitrogen production.
Urea Nitrogen Reutilization
Discussion of urea metabolism would be incomplete
without addressing urea degradation. It is calculated from
the plasma disappearance of injected [14C]urea or [15N]
urea (88,90) and averages about 3.6 g nitrogen/d in both
normal individuals and patients with uremia. The 3.6 g
nitrogen/d arises from degradation of urea by ureases of
gastrointestinal bacteria thereby supplying ammonia directly to the liver (88). Because this source of nitrogen
could be used to synthesize amino acids and ultimately
protein, the degradation of urea has been intensively studied (91). The evidence negates the hypothesis that urea
degradation is nutritionally important. First, the amount
of urea degraded has been expressed as an extrarenal
urea clearance by dividing the rate of urea degradation
by the SSUN. In normal adults, the extrarenal urea clearance
averages approximately 24 L/d; if this value were present in
patients with CKD and a high SUN, the amount of ammonia
derived from urea would be very high (79,88). However, the
quantity of ammonia arising from urea in patients with CKD
is not signicantly different from that of normal individuals,
indicating that the extrarenal clearance of urea in patients
with CKD must be greatly reduced; the mechanism for this
observation is unknown (88).
Results from other testing strategies lead to the conclusion that it is unlikely that urea degradation contributes a
nutritionally important source of amino acids to synthesize
protein. We fed patients with CKD a protein-restricted diet
and measured the turnover of urea using [14C]urea. The
results were compared with those obtained in a second
experiment in which patients received neomycin/kanamycin as nonabsorbable antibiotics in order to inhibit bacteria
that were degrading urea. In roughly half of the patients,
antibiotic administration blocked urea degradation but
there was no associated increase in urea appearance.
This result means that ammonia arising from degradation
A 60-year-old man with stage 5 CKD is admitted to the hospital for plastic surgery. He weighs 70 kg and has been taught
to follow a diet containing 40 g protein/d (6.4 g nitrogen/d because protein is 16% nitrogen). He excretes 4 g urea
nitrogen/d, but on day 2 his BUN rises from 50 to 60 mg/dl.
c The increase in BUN signies accumulation of urea nitrogen in body water (70 kg x 0.6 L/kg x 0.1 g urea
nitrogen/L = 4.2 g urea nitrogen/d).
c His NUN is 70 kg x 0.031 g nitrogen/kg per day = 2.17 g nitrogen/d.
c The total nitrogen excreted and accumulated is approximately 10 g/d (4 g urea nitrogen excreted/d +2.17 g
NUN/d + 4.2 g urea nitrogen accumulated/d = 10.3 g nitrogen/d).
c Because his nitrogen excretion substantially exceeds the dietary nitrogen of 6.4 g/d, he requires a consultation with
a nutrition/dietician and testing for gastrointestinal bleeding
SUN, serum urea nitrogen; NUN, nonurea nitrogen excretion.
13
Acknowledgments
The preparation of this review was supported by funds from the
National Institutes of Health (R37-DK037175 to W.E.M., R01-DK045788
to I.D.W., and R01-DK089828 and R21-DK091147 to J.M.S.) and the US
Department of Veterans Affairs (1I01BX000818 to I.D.W.).
Disclosures
None.
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